Hospital-Based Fall Program Measurement and Improvement
The trend to advance patient safety and quality in health care organizations is based on implementing the concepts of high reliability organizations (HRO). Experts (Pronovost et al., 2006; Weick & Sutcliffe, 2007) agree that high reliability organizations are those that achieve a high degree of safety or reliability despite dangerous or hazardous conditions. The nuclear and airline industries are noted as some of the most hazardous industries and have often been cited for their defect-free or error-free operations for long periods of time. Case studies of the Three Mile Island nuclear incident, the Challenger and Columbia explosions, the Tenerife air crash and other events examine how these events occurred and the similarities in these high risk situations, giving rise to studying and defining reliability in hazardous organizations. This study of HROs can lead to organizational behaviors that demonstrate anticipation, resilience, and constant improvement (Weick & Sutcliffe, 2007).
Based on the HRO model, many compare health care organizations as aspiring to emulate characteristics of other HROs to minimize errors and achieve exceptional performance in patient safety and quality. There are great opportunities to improve by moving in this direction. Some studies indicate that core processes in health care are defective 50% of the time and patients receive only about 55% of the appropriate care when entering the health care system (McGlynn et al., 2003;Resar, 2006).
Efforts to lead this improvement movement come from a variety of sources such as those noted earlier (e.g., CMS HACs for the Hospital Inpatient Quality Reporting Program, TJC Center for Transforming Healthcare with Targeted Solutions Tools, AHRQ, NDNQI measurement system, and NQF "never events"). Each of these organizations and/or initiatives promotes error or defect free health care through interventions and measures that support this goal. There is clearly a unified goal across organizations to support a culture for patient safety and quality of care through continuous improvement and systems, which must also include measurement systems.
High Reliability Organizations: Current Model
The trend to advance patient safety and quality in health care organizations is based on implementing the concepts of high reliability organizations (HRO). Experts (Pronovost et al., 2006; Weick & Sutcliffe, 2007) agree that high reliability organizations are those that achieve a high degree of safety or reliability despite dangerous or hazardous conditions. The nuclear and airline industries are noted as some of the most hazardous industries and have often been cited for their defect-free or error-free operations for long periods of time. Case studies of the Three Mile Island nuclear incident, the Challenger and Columbia explosions, the Tenerife air crash and other events examine how these events occurred and the similarities in these high risk situations, giving rise to studying and defining reliability in hazardous organizations. This study of HROs can lead to organizational behaviors that demonstrate anticipation, resilience, and constant improvement (Weick & Sutcliffe, 2007).
Based on the HRO model, many compare health care organizations as aspiring to emulate characteristics of other HROs to minimize errors and achieve exceptional performance in patient safety and quality. There are great opportunities to improve by moving in this direction. Some studies indicate that core processes in health care are defective 50% of the time and patients receive only about 55% of the appropriate care when entering the health care system (McGlynn et al., 2003;Resar, 2006).
Efforts to lead this improvement movement come from a variety of sources such as those noted earlier (e.g., CMS HACs for the Hospital Inpatient Quality Reporting Program, TJC Center for Transforming Healthcare with Targeted Solutions Tools, AHRQ, NDNQI measurement system, and NQF "never events"). Each of these organizations and/or initiatives promotes error or defect free health care through interventions and measures that support this goal. There is clearly a unified goal across organizations to support a culture for patient safety and quality of care through continuous improvement and systems, which must also include measurement systems.
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